الفهرس 
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Abstract
SUMMARY
There are significant changes in the world resulting from globalization, information
technology, and increased competition worldwide that have largely changed education and
working conditions. Nursing students as future healthcare providers are considered a critical
key part of any healthcare organization and will have the most important role in those
organizations. Among the important predictors of the continued success and viability of
healthcare organizations especially hospitals are the favorable attitudes towards clinical
practice that can be affected by holistic and systems thinking.
Systems thinking is a dynamic process that examines complex patterns, connections,
and relationships within structures to enable the recognition of the overall picture. A higher
level of ST is associated with dealing with different mindsets and complex situations,
understanding issues by viewing its big picture and examining it from multiple angles, and
acquiring experiences from training in clinical areas. ST helps nursing students in making
effective informed decisions, dealing with complex challenging situations they may encounter
during their clinical training, and affecting their attitudes towards clinical practice. Attitude is
a student’s predisposed mental condition towards a value and it arises by a responsive
expression towards any object which in turn affects a student’s thoughts and behaviors.
Moreover, clinical practice is an essential element that enables nursing students to apply
theoretical knowledge in the real environment and to train through interaction with patients
and health workers.
Aim of the study:
This study aimed to determine the relationship between systems thinking pattern and
attitudes towards clinical practice as perceived by nursing students at Damanhour University.
Research design:
A descriptive, correlation research design was used to conduct this study.
Setting of the study:
This study was conducted at Faculty of Nursing, Damanhour University which includes
nine scientific departments namely: Nursing Administration, Medical and Surgical Nursing,
Pediatric Nursing, Gerontology Nursing, Community Health Nursing, Obstetric and
Gynaecological Nursing, Psychiatric and Mental Health Nursing, Critical Care and
Emergency Nursing, and Nursing Education.
Subjects of the study:
Probability simple random sample from students (n=365) enrolled in the second, third,
and fourth academic year in the Faculty of Nursing, Damanhour University 2022-2023, who
were available during the time of data collection, also, they were willing to participate in this
study. They were divided as follows: second-year students (n=80), third-year students
(n=170), and fourth-year students (n=115) based on proportion allocation method (14.6% of
the total students from each previously chosen academic year). First-year students and
Technical Health Institute students in the second year were excluded from this study because
their numbers were unavailable in the academic year 2021-2022 at the students’ affairs
department. Furthermore, at the beginning of the academic year 2022-2023 (during data
Summary
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collection) their numbers were not fixed as they were vulnerable to either increase or decrease
later.
Tools of the study:
The study used two tools for data collection.
Tool I: Systems thinking pattern survey:
It was developed by Johnson (2021)(186) and was adapted by the researcher according to
Egyptian nursing students’ culture to assess students’ systems thinking, it is composed of 28
items. Responses of the students were measured on a 3-point Likert rating scale includes: (0)
false, (1) uncertain, and (2) true. The reversed scores were applied for negative statements.
The overall score level ranged from (0 to 56) and was categorized as follows: low score of
systems thinking from (0-28), moderate score of systems thinking from (29-43), and high
score of systems thinking from (44-56). The overall score was also, calculated according to
mean percent score as follows; low systems thinking pattern < 50 %, moderate systems
thinking pattern 50 % <75 %, and high systems thinking pattern ≥ 75 %.
Tool II: Attitudes towards clinical practice questionnaire:
It was developed by Ha (2015)(19) and was adapted by the researcher according to
Egyptian nursing students’ culture to assess nursing students’ attitudes towards clinical
practice. It consists of 43 items grouped under two main dimensions namely: enthusiastic
attitude (29 items) and querulous attitude (14 items). Responses of the students were
measured on a 5-point Likert rating scale ranging from (1) strongly disagree to (5) strongly
agree. The overall score level ranged from (43 to 215) and was categorized as follows;
negative attitudes towards clinical practice from (43-129), fair attitudes towards clinical
practice from (130-173), and positive attitudes towards clinical practice from (174-215). The
overall score was also, calculated according to mean percent score as follows; negative
attitudes towards clinical practice < 50 %, fair attitudes towards clinical practice 50 % < 75
%, and positive attitudes towards clinical practice ≥ 75 %.
Methods
1. An official permission was obtained from the Dean of Nursing Faculty, Damanhour
University for data collection.
2. The two tools were translated into Arabic by the researcher and were submitted into
both Arabic and English languages to a jury of five experts in the field of the study to
test its content validity and translation. Accordingly, the necessary modifications were
done based on their opinions.
3. A pilot study was carried out on 10% of the total sample size (n=36) of nursing
students, who were excluded from the study subjects; to check and ensure the clarity of
items feasibility of the tool and to identify obstacles and problems that may be
encountered during data collection. Based on the findings of the pilot study, no
modifications were done.
4. Reliability analysis: The two tools were tested for their reliability by using Cronbach’s
alpha correlation coefficient test to measure the internal consistency of items. The two
tools were proved to be reliable where r=0.717 for tool I (Systems Thinking Survey)
and r=0.881 for tool II (Attitudes towards Clinical Practice Questionnaire) at a
statistical significance level ≤ 0.05.
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Data collection:
Data were collected from the nursing students at all scientific departments through the
distribution of self-administered questionnaires after explaining the aim of the study
using the previously mentioned tools. Instructions were given after obtaining informed
consent from the study subjects before the distribution of the questionnaires.
The questionnaires were completed in the presence of the researcher to ensure the
objectivity of students’ responses, non-contamination of their opinions, and to check
that all items were answered.
Answering the questionnaires took approximately from 15-20 minutes. Data collection
took a period of two months starting from the beginning of October 2022 to the end of
November 2022. All questions were answered and explanations were given accordingly.
Ethical Considerations:
The research approval was obtained from the ethical committee at the Faculty of
Nursing- Damanhour University prior to the start of the study.
A written informed consent was obtained from the study subjects after an explanation of
the aim of the study.
Privacy and the right to refuse to participate were ensured during the study.
Confidentiality and anonymity regarding data collected were maintained.
Data statistical analysis:
Suitable statistical analysis tests were used to identify significant relations and to
answer the research question. After collecting data, they were revised, coded, transferred into
the designed format, to be fed to the computer using statistical IBM SPSS (Statistical Package
for the Social Sciences) software package version 20.0. (Armonk, NY: IBM Corp) Qualitative
data were described using number and percent.
The following statistical analysis were used.
A. Descriptive statistics: in forms of frequencies, percent, and mean with standard
deviation, to describe categorical data.
B. Analytical statistics:
1. Cronbach’s Alpha:
It was done to assess the reliability of the systems thinking survey and attitudes towards
clinical practice questionnaire using Cronbach’s Alpha correlation coefficient test.
2. Chi-square test:
It was done for categorical variables, to compare between different groups.
3. Student T-Test:
It is a parametric statistical test that used for normally distributed quantitative variables,
to compare between two studied categories.
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4. F-test (ANOVA test):
It is a parametric statistical test that used to compare the mean for two quantitative data
of more than two independent groups that follow a normal distribution.
5. Pearson coefficient:
It was done to measure the correlation between systems thinking pattern and attitudes
towards clinical practice as perceived by nursing students.
6. Linear regression
It was done to detect the most affecting factor for affecting attitudes towards clinical
practice
C. Correlation analysis
Correlation was used to test the nature and strength of relation between two
quantitative/ ordinal variables. Pearson’s Correlation coefficient was used.
The following were the main results of the present study:
1. There was a high statistical significant difference between nursing students in the three
academic years regarding their age and previous work (p≤0.001), while there was a
statistical significant difference between them regarding their arrangement among
siblings (p=0.010). On the other hand, there were no statistical significant difference
between nursing students in the three academic years regarding their gender and
marital status (p=0.067,p=0.123) respectively.
2. The result indicated that there was a statistical significant difference between nursing
students in the three academic years regarding their levels of ST pattern (p=0.041).
Furthermore, it revealed that more than two-thirds of the nursing students (69%)
perceived moderate level of ST pattern.
3. The study confirmed that there was no statistical significant difference among nursing
students in the three academic years regarding their levels of overall attitudes towards
clinical practice and its dimensions namely: enthusiastic attitude and querulous attitude
(p=0.111, p=0.074, p=0.456) respectively. Moreover, it revealed that the vast majority
of nursing students (85%) perceived fair overall attitudes towards clinical practice.
4. There were no statistical significant relations between nursing students’ demographic
characteristics in the three academic years namely; age, gender, arrangement among
siblings, marital status, and previous work and levels of ST pattern as perceived by
them (p>0.05).
5. There was no statistical significant relation between nursing students’ demographic
characteristics in the three academic years namely; age, gender, arrangement among
siblings, and marital status and levels of attitudes towards clinical practice as perceived
by them (p>0.05). While, there was a statistical significant difference between their
demographic characteristic namely; previous work and levels of attitudes towards
clinical practice as perceived by them (p=0.021).
6. There was a high statistical significant weak correlation between the overall ST pattern
and the overall attitudes towards clinical practice as perceived by the nursing students
in the three academic years (r=0.210, p<0.001).
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7. This study revealed that ST as independent variable can predict about 4.4% of attitudes
towards clinical practice as dependent variable.
The findings of this study lead to the following recommendations:
A- Recommendations for faculty administrators:
Conduct frequent training programs and a series of workshops on ST for academic
professors, clinical instructors, and nursing students to increase their ST knowledge
and skills.
Integrate the ST concept in the faculty theoretical and clinical curriculum to encourage
nursing students to use ST in their scientific and practical lives.
Integrate the concept of ST into the postgraduate curriculum to raise their awareness
towards values, attitudes, and behaviors that are necessary while facing complex issues
and making decisions.
Foster a positive learning culture for nursing students to promote their ST pattern
through participating in problem-solving and decision-making processes.
Allow the availability of counselor educators in the faculty to expand nursing students’
ST which will, in turn, influence their attitudes and behaviors by convincing them to
study the art of etiquette subject as an elective subject.
B- Recommendations for academic professors and clinical instructors:
Develop training programs for nursing students to increase their awareness of ST and
its potential consequences on their attitudes.
Conduct periodic meetings with nursing students by scheduling announced hours of
academic guidance professors to discuss the problems they encounter in clinical areas,
discuss ways of solving those problems, and give them opportunities to participate in
problem-solving and decision making which will ,in turn, influence their ST.
Provide nursing students with constructive feedback continuously about their
performance in clinical areas to enhance their clinical practice attitudes.
Motivate nursing students by providing psychological and spiritual support in the
condition of falling into mistakes and appreciating differences in values, ideas, and
opinions to enhance their attitudes towards clinical practice in clinical areas.
Encourage teamwork and group dynamics to promote the exchange of thoughts and
attitudes among them during their presence in the lab, clinical areas,…etc.
C- Recommendations for nursing students:
Engage in teamwork rather than work individually.
Respect other’s values, beliefs, and points of view.
Demonstrate appropriate and respectful behavior towards patients, healthcare
providers, and colleagues.
Monitor and self-appraise their academic, practical, and personal development.
Visit the counselor educator of the faculty to help them with the challenges they face
to enhance their well-being through scheduled announced hours.
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Further research studies:
• Effect of ST training program for nursing students on their attitudes towards clinical
practice in different educational institutions.
• The relationship between ST pattern and nursing students’ civility.
• The effect of ST pattern on the nursing students’ innovation and creativity.
• Factors influence nursing students’ ST pattern in governmental and private educational
institutions: A comparative study.
• Compare the results of this study with the studies’ findings conducted in other
environments.